Surgical techniques of tracheostoma reconstruction
The simplest method of widening the stoma is the dilatation of the stenosis by the use of cannulas and buttons. However, this is usually only a temporary solution as it does not remove the stenotic scar tissue and may aggravate it.
Various more or less elaborate techniques have been described to reconstruct a stenotic tracheostoma. Previous radiotherapy does not preclude reconstruction, but can make surgery more difficult. Excision of the stenotic scar tissue is the first step, which has to be performed to prevent recurrent stenosis. Excess subcutaneous tissue and fat have to be excised as well as overhanging skin flaps. If necessary, the remaining thyroid lobe has to be lateralized if it is bulging into the stoma borders.
Sometimes it is also necessary to resect the sternal heads of the sternocleidomastoid muscles if they deepen the lateral walls of the tracheostoma, and when one has already been removed as part of a neck dissection, the opposite sternal head should be cut to obtain a symmetrical surface. Apart from these common steps, the reconstructions can be classified into three categories. In each category minor variations have been described but the principles are essentially the same within each group.
The first technique consists of removing the stenotic part of the stoma with about a centimeter of skin and simple suture of the skin to the tracheal wall. This so-called ‘doughnut method’ is probably the oldest method.4 It has the disadvantage that it does not interrupt the line of circular wound healing which is prone to recurrent stenosis. Most of the variations of this technique consist of the creation of lateral traction of the walls in an attempt to prevent a new stenosis.12 Some also advocate the use of radial incisions with subsequent dilatation with cannulas.12 We believe this latter method to be more likely to cause recurrent stenosis, since lack of primary wound healing may lead to more fibrosis.
The second group of reconstructions consists of inserting a cutaneous flap in the dorsal part of the upper trachea.1,4,13,14 Not only does this result in widening of the diameter of the stoma but it also causes an interruption of the circle of scar tissue, thereby decreasing the risk of a new stenosis (figures below). Several modifications have been described but they all have in common the use of a posterior skin flap.2,5,15,16
This technique usually succeeds in increasing he diameter of the stoma, but it can interfere with prosthetic voice rehabilitation, since the dorsal part of the tracheostoma becomes covered with skin. That part of the tracheostoma is the location of the tracheoesophageal (TE) fistula and thus the voice prosthesis. Therefore, if a prosthesis is already in situ, it may have to be removed and reinserted at a later date. Consequently, the patient loses his voice for at least several weeks. Furthermore, the thickness of the skin might complicate the insertion of a new prosthesis. The common wall of trachea and esophagus may become too thick for the current types of prostheses.